At a press telecon yesterday Boeing outlined in more detail the cause of the failure of one main parachute to deploy during its November 4 Starliner pad abort test.

In a call with reporters, John Mulholland, vice president and program manager for commercial crew at Boeing, said an investigation after the Nov. 4 test at White Sands Missile Range in New Mexico led the company to conclude that a “lack of secure connection” between a pilot parachute and the main parachute prevented that main parachute, one of three, from deploying.

The pilot parachute is designed to deploy first, and pull out the main parachute. However, Mulholland said that hardware inspections and photographs taken during “closeout” of the vehicle prior to the test showed that a pin that links the pilot and main parachutes was not inserted properly.

“It’s very difficult, when you’re connecting that, to verify visually that it’s secured properly,” he said, in part because that portion of the parachute system is enclosed in a “protective sheath” intended to limit abrasion but which also makes it difficult to visually confirm the pin is in place. “In this particular case that pin wasn’t through the loop, but it wasn’t discovered in initial visual inspections because of that protective sheath.”

Mulholland said Boeing is modifying assembly procedures through what he called “fairly easy steps,” such as pull tests, to ensure those pins are properly installed. Technicians have already confirmed that the same parachute linkages are properly installed on the three parachutes on the Starliner that will launch in December on an orbital flight test to the International Space Station. [emphasis mine]

That a hardware inspection and photos taken before launch revealed this issue and resulted in nothing being done should rise serious questions at Boeing about its quality control processes. Based on the press telecon, however, it does not appear that Boeing is asking those questions. From a different report:

[John Mulholland, Boeing’s Starliner program manager] praised the rigging team, saying “even before we got eyes on the hardware, that team on their own initiative (was) reviewing the close-out photos and the processes, and they identified the potential issue that was subsequently validated by hardware inspection.”

“Most importantly, they raised their hand and and let us know what they believe the problem was,” he said. “It’s really a testament to the transparency of that team. The speak-up culture that we have, that is what we need on this program.”

While it is good that the rigging team was willing to speak up afterward, it is very bad that their procedures allowed the launch to go forward. The company says it has now changed its rigging procedures, but I don’t sense any effort on Boeing’s part to find out why its so-called “speak-up culture” failed to have these engineers speak-up, before launch.